Wiley

Journal of Diabetes Research

Volume 2024, Article ID 5110867, 12 pages
https://doi.org/10.1155/jdr/5110867

Research Article
Analysis of Influencing Factors Related to Health Literacy of
Diabetic Patients: A Survey Based on DHLEIS

Yalan Chen , Zepeng Wang , Fangyuan Jiang , Junyi Shi , and Kui Jiang
Department of Medical Informatics, School of Medicine, Nantong University, Nantong, Jiangsu, China

Correspondence should be addressed to Kui Jiang; kuij@ntu.edu.cn

Received 19 July 2024; Accepted 11 November 2024

Academic Editor: Syed Anees Ahmed

Copyright © 2024 Yalan Chen et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Purpose: This study is aimed at investigating health literacy (HL) among diabetes mellitus (DM) patients using a comprehensive,
scientific, feasible, and suitable HL assessment indicator system tailored for the diabetic population in mainland China and
systematically analyzing the factors influencing HL in this population.
Methods: The Delphi expert consultation method was employed to initially draft and refine the Diabetes Health Literacy
Evaluation Indicator System (DHLEIS). The reliability and representativeness of the indicator system were tested through
metrics including the active coefficient, authority degree, and coordination degree. A HL survey questionnaire for diabetic
patients was developed based on DHLEIS and administered to diabetic patients across five hospitals in Nantong and Yancheng
cities, Jiangsu Province. The random forest method was utilized to deeply analyze the impact of various factors on HL and its
four dimensions and to identify the core influencing factors.
Results: Analysis of 707 questionnaires based on the DHLEIS revealed that nine factors—age, sex, body shape, income, exercise,
education level, duration of DM, whether insulin is injected, and the number of cohabitants—significantly impact the HL levels.
Among these, age, duration of DM, education level, and number of cohabitants were particularly influential across the four
dimensions of health knowledge, awareness, behavior, and skills. Factors related to health knowledge and skills were the most
significant contributors to overall HL.
Conclusions: The multidimensional analysis of factors influencing HL offers valuable insights into characterizing varying levels of
HL among diabetic patients. This approach supports targeted cognitive improvements and the effective enhancement of health
skills, ultimately leading to better health outcomes.

Keywords: diabetes; evaluation index system; health literacy; influencing factors

1. Introduction economic development, lifestyle changes, accelerated urban-

ization, an aging population, and other factors have all con-
Diabetes mellitus (DM) is a chronic noncommunicable dis- tributed to a marked increase in the prevalence of DM in
ease caused by metabolic disorders influenced by factors China.
such as genetics and environment. These disorders can In the 1970s, Simonds first introduced the concept of
result in chronic damage, dysfunction, or even failure of “health literacy” (HL) at a health education conference,
multiple organs. With its high prevalence, disability rate, advocating for the establishment of minimum standards
and mortality rate, DM poses a silent but serious threat to for HL [3]. Over the past half-century, the definition and
global health. It is estimated that the number of diabetic scope of HL have been continuously refined and expanded.
patients will rise to 643 million by 2030 and 783 million by The most widely recognized definition describes HL as the
2045 [1, 2]. China, which has the largest population of indi- ability of individuals to obtain, understand, and use basic
viduals with DM, faces significant challenges in its preven- health information and services to make informed health
tion and management. The rapid pace of social and decisions, thereby maintaining and promoting their health
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2 Journal of Diabetes Research

[4]. For diabetic patients, HL specifically refers to their abil- 2. Materials and Methods
ity to gather, comprehend, and use health education infor-
mation and healthcare services related to DM, with the 2.1. Determination of the Indicator System and Weights
goal of managing and improving their condition [5]. 2.1.1. Construction of the DHLEIS Framework. Based on the
Research indicates that over 80% of chronic diseases can concepts and definitions of HL and EHL and incorporating
be prevented by adopting a healthy lifestyle [6]. In 2022, the the knowledge–attitude–practice theory as well as the “66
American Diabetes Association and the European Association Health Literacy Principles” [20], a preliminary two-tier indi-
for the Study of DM released a consensus report recommend- cator system framework for assessing the HL of diabetic
ing that social determinants of health, healthy lifestyle behav- patients was developed. Experts rated each indicator on a
iors, and DM self-management education and support be 5-point scale: very important (5 points), quite important (4
considered integral components of DM care. However, points), average (3 points), not very important (2 points),
achieving these goals requires patients to have good HL, which and not important (1 point).
is crucial for managing their health and making appropriate
health decisions [7]. Studies have shown that diabetic patients 2.1.2. Weight determination. After two rounds of expert con-
with inadequate HL often lack essential health-related knowl- sultations and feedback, the indicator system was refined,
edge, demonstrate poorer medication adherence, have weaker and the weights of each level of indicator were determined
communication and interaction with healthcare professionals, using the coefficient of variation method.
and participate less frequently in health decision-making [8].
Therefore, systematically studying the factors that influence 2.2. Development of the HL Questionnaire. A HL question-
HL in diabetic patients and effectively improving their HL naire for diabetic patients was designed based on the
levels are vital strategies for the prevention and control of DM. DHLEIS framework. After multiple rounds of pretesting
Although most studies suggest that there is still a lack of and revisions, the final version of the HL survey for diabetic
a universally recognized screening tool to assess HL [9], the patients was established. The reliability and validity of the
rapid development of artificial intelligence (AI) technology questionnaire were assessed using Cronbach’s α coefficient,
and the growing emphasis on electronic health literacy coordination coefficient, and authority coefficient.
(EHL) have introduced new dimensions to research on HL
assessment and influencing factors. Brown et al. [10] 2.3. Study Population. According to the basic principles of
explored the use of natural language processing techniques questionnaire development and psychometric properties,
and machine learning (ML) to develop a novel, effective, there is a positive relationship between the number of
and scalable method for measuring patient HL. Similarly, items on a scale and the required sample size, with a ratio
Hæsum, Cichosz, and Hejlesen [11] applied ML methods of five to 10 participants per item [21]. Given that the
to refine the influencing factors and evaluation items of HL questionnaire consists of 39 items, the required sample
in patients with chronic obstructive pulmonary disease, aim- size ranges from 195 to 390 participants. The inclusion
ing to create a concise HL assessment tool. To date, AI has criteria for participants were adults aged 21 and over
seen extensive applications in DM risk prediction [12], dia- who met the World Health Organization (WHO) diagnos-
betic retinopathy detection [13], and wearable device- tic standards for DM and were capable of independently
assisted intelligent DM management [14, 15]. In the fields communicating with the interviewers. Exclusion criteria
of HL and health education, emerging research includes included pregnant women and individuals with cognitive
the use of ML to identify key sociodemographic variables impairments.
for HL modeling [16] and the development of AI-based pre- Following a preliminary study, an anonymous survey
cise linkage systems for health education [17]. was conducted using convenience sampling from January
A systematic evaluation of HL intervention trials for dia- 2022 to December 2022 in the outpatient and inpatient
betic patients in mainland China revealed numerous departments of five hospitals in Nantong and Yancheng
influencing factors, a wide range of intervention models, cities, Jiangsu Province. A total of 820 diabetic patients
and various assessment scales that are often overly broad voluntarily participated and completed the survey. Prior
and lack comprehensive evaluation dimensions [18, 19]. to the survey, interviewers were recruited and trained at
This highlights the need for a scientific, comprehensive, each of the five hospitals to ensure consistent data
and tailored HL evaluation indicator system specifically collection.
designed for the diabetic population in mainland China.
Such a system would enable accurate assessment of the core 2.4. ML and Visualization Analysis. Random forest (RF) is a
factors influencing HL among diabetic patients and effec- ML ensemble algorithm used for classification and regres-
tively enhance their HL levels. To achieve this, the study sion, capable of effectively identifying key influencing factors
employed the Delphi expert consultation method to develop by integrating multiple decision trees [22]. Given the diver-
the Diabetes Health Literacy Evaluation Indicator System sity and complex nonlinear relationships among HL-
(DHLEIS) and designed a multidimensional questionnaire related variables, RF contribution analysis was employed to
to investigate the factors affecting HL in diabetic patients. extract the core factors influencing HL levels in diabetic
This study is aimed at providing a theoretical foundation patients. Principal component analysis (PCA) is commonly
for medical professionals to quickly assess the HL of diabetic used to assess the dimensional structure of datasets or to
patients and more precisely address adverse factors. reduce a large number of variables into a smaller set of linear
 1485, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/jdr/5110867, Wiley Online Library on [30/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Journal of Diabetes Research 3

Table 1: Evaluation index system of health literacy of DM population and its corresponding weight.

Primary indicators Secondary indicators

A1. Believing that health is more important than money (0.025)
A2. Willing to spend time and money improving health (0.031)
A3. Willing to access health education information (0.033)
A. Health awareness (0.185)
A4. Willing to change one’s unhealthy lifestyle habits (0.023)
A5. Willing to receive professional guidance from doctors or nurses (0.010)
A6. Willing to receive peer education (0.052)
B1. Understand the blood glucose control standards of diabetic patients
(fasting blood glucose, blood glucose 2 h after meal, and glycosylated hemoglobin) (0.010)
B2. Understand the main symptoms and complications of diabetes (0.021)
B3. Master the basic nursing methods of diabetes (0.019)
B4. Understand the significance of regular return visits to diabetes (0.021)
B5. Understanding the treatment methods for hypoglycemia (0.010)
B6. Understand the significance of diet control on the control of diabetes (0.010)
B7. Understanding the meaning of food glycemic index (0.041)
B. Health knowledge (0.185)
B8. Understand which diet is suitable for one’s own health condition (0.029)
B9. Understanding the importance of mental health (0.033)
B10. Understanding the manifestations of psychological issues such as anxiety and depression (0.037)
B11. Understand the side effects of diabetes-related drugs (0.027)
B12. Mastering the correct use of hypoglycemic drugs (0.010)
B13. Understand the relevant knowledge required to use a computer to access the internet
(browser, website, and search tools) (0.039)
B14. Learn about using smartphones to obtain health support (APP and WeChat official account) (0.035)
C1. Nonsmoking (0.023)
C2. Not drinking alcohol (0.033)
C3. Ensure 7–8 h of sleep per day (0.033)
C4. Reasonably arrange one’s daily diet (0.010)
C. Health behavior (0.260) C5. Annual regular physical examination (0.014)
C6. Persist in using scientific and reasonable methods for physical exercise (0.014)
C7. Exercise for at least half an hour every day (0.019)
C8. Actively cooperate with doctors or nurses for examination (0.014)
C9. Discover health issues and seek medical attention promptly (0.027)
D1. Can read written information such as medical orders and drug instructions (0.019)
D2. Be able to use medication correctly according to medical advice (or inject insulin correctly) (0.014)
D3. Be able to use a blood glucose monitor correctly (0.019)
D4. Can use smart monitoring devices such as smartphones or wearable devices to
monitor one’s own health data (0.033)
D5. Able to seek medical treatment online (online registration, doctor-patient
online communication, etc.) (0.045)
D. Health skills (0.370)
D6. Can use the internet to search for necessary health education information (0.033)
D7. Can use traditional media such as paper literature and bulletin boards to obtain
health education information (0.035)
D8. Able to communicate with professionals to obtain health education information (0.040)
D9. Can understand and judge the correctness of the health education information obtained (0.030)
D10. Being able to make decisions that are beneficial for improving one’s own health status
based on one’s own health status and educational information (0.029)

combinations, facilitating hierarchical clustering or associa- analyses of the relevant influencing factors were conducted
tion determination [23, 24]. In this study, PCA was used to using RStudio, while multidimensional visualization analy-
validate the effectiveness of the ML approach. Statistical ses were performed using OriginPro software.
 1485, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/jdr/5110867, Wiley Online Library on [30/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
4 Journal of Diabetes Research

Table 2: Basic information of the survey subjects.

Survey items Subgroups HL-adequate (n = 387) HL-deficient (n = 320) p value

Male 251 (64.9) 159 (49.7) < 0.001
Sex (%)
Female 136 (35.1) 161 (50.3)
< 30 27 (7.0) 3 (0.9) < 0.001
30–49 104 (26.9) 30 (9.4)
Age (%)
50–79 240 (62.0) 252 (78.8)
80+ 16 (4.1) 35 (10.9)
<5 167 (43.2) 116 (36.2) 0.039
5–9 95 (24.5) 79 (24.7)
DM duration (%) 10–14 42 (10.9) 42 (13.1)
15–19 43 (11.1) 58 (18.1)
20+ 40 (10.3) 25 (7.8)
T1DM 30 (7.8) 23 (7.2) 0.888
DM type (%)
T2DM 357 (92.2) 297 (92.8)
Yes 133 (34.4) 101 (31.6) 0.479
Family history (%)
No 254 (65.6) 219 (68.4)
Standard 174 (45.0) 147 (45.9) 0.636
Obesity 56 (14.5) 39 (12.2)
Body shape (%)
Overweight 108 (27.9) 99 (30.9)
Lean 49 (12.7) 35 (10.9)
Single 14 (3.6) 10 (3.1) 0.1
Marital status (%) Married 368 (95.1) 298 (93.1)
Divorced/widowed 5 (1.3) 12 (3.8)
ILL 3 (0.8) 43 (13.4) < 0.001
PS 44 (11.4) 91 (28.4)
JHS 124 (32.0) 118 (36.9)
Education level (%)
SEC 122 (31.5) 50 (15.6)
UG 91 (23.5) 17 (5.3)
MA+ 3 (0.8) 1 (0.3)
< 3000 28 (7.2) 42 (13.1) < 0.001
3000~5000 120 (31.0) 126 (39.4)
Income (%) 5000~10,000 120 (31.0) 62 (19.4)
> 10,000 87 (22.5) 52 (16.2)
Unclear 32 (8.3) 38 (11.9)
Yes 166 (42.9) 157 (49.1) 0.118
Complication (%)
No 221 (57.1) 163 (50.9)
No 268 (69.3) 255 (79.7) 0.002
Exercise (%)
Yes 119 (30.7) 65 (20.3)
No 113 (29.2) 104 (32.5) 0.387
Dietary control (%)
Yes 274 (70.8) 216 (67.5)
No 114 (29.5) 88 (27.5) 0.624
OHA (%)
Yes 273 (70.5) 232 (72.5)
No 383 (99.0) 316 (98.8) 1
No intervention (%)
Yes 4 (1.0) 4 (1.2)
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Journal of Diabetes Research 5

Table 2: Continued.

Survey items Subgroups HL-adequate (n = 387) HL-deficient (n = 320) p value

1 19 (4.9) 24 (7.5) < 0.001
2 183 (47.3) 179 (55.9)
3 114 (29.5) 36 (11.2)
No. of cohabitant (%) 4 25 (6.5) 30 (9.4)
5 35 (9.0) 27 (8.4)
6 11 (2.8) 21 (6.6)
7 0 (0.0) 3 (0.9)
Note: p < 0 05, statistically significant.
Abbreviations: DM, diabetes mellitus; HL, health literacy; ILL, illiterate; JHS, junior high school; OHA, oral hypoglycemia agent; PS, primary school; SEC, high
school/vocational school/technical secondary school; UG, college/undergraduate.

Education level Age

Age Education level

No. of cohabitant DM duration

Income No. of cohabitant

Injection Income

Body shape Body shape

Exercise Injection
Features

DM duration Sex

Sex Exercise

Dietary control Family history

Family history Complication

Complication Dietary control

No intervention OHA

OHA Marital status

Marital status DM type

DM type No intervention

–5 0 5 10 15 20 25 30 35 40 45 0 5 10 15 20 25 30 35 40

%IncMSE Mean decrease in impurity

Figure 1: Analysis of the importance of basic information on health literacy. The further to the right a point is, the greater the impact of that
factor on health literacy. DM, diabetes mellitus; OHA, oral hypoglycemia agent.

3. Results A corresponding survey questionnaire was developed

based on the DHLEIS (detailed content is available in Support-
3.1. Questionnaire Design Based on the DHLEIS Framework. ing Information S1). The questionnaire categorizes the overall
After two rounds of expert consultations and feedback revi- influencing factors of diabetic patients’ HL into two sections:
sions, the DHLEIS framework and content were finalized, (1) personal basic information, including variables such as
comprising four primary indicators (health awareness, sex, age, duration of illness, and education level; and (2) infor-
health knowledge, health behavior, and health skills) and mation across the four dimensions, with each of the 39 sec-
39 secondary indicators. The specific content and weights ondary indicators corresponding to a specific question. The
of each indicator are presented in Table 1. questionnaire includes two main types of questions: (1)
 1485, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/jdr/5110867, Wiley Online Library on [30/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
6 Journal of Diabetes Research

160
120 180
140 160
100 120 140
80 100 120
Count

Count

Count
80 100
60
80
60
40 60
40
40
20 20 20
0 0 0
20 40 60 80 100 0 10 20 30 40 Stand Overweight Lean Obesity

Age DM.duration Body shape

140 140 120
120 120 100
100 100
80
80 80
Count

Count

Count
60
60 60
40
40 40
20 20 20

0 0 0

F&E&Int

F&E&NoInt

F&I&NoInt

F&I&Int

M&I&Int

M&E&NoInt

M&I&NoInt

M&E&Int
PS JHS UG SEC ILL MA+ <3K 3-5K 5-10K 10K+ Unknown

Education level Income

High health literacy

Low health literacy
SEI

Figure 2: Distribution of health literacy levels across different demographic characteristics. Horizontal axis represents different
characteristic values or categories. Vertical axis represents counts (population density). Color represents two levels of health literacy. DM,
diabetes mellitus; F, female; M, male; Int, insulin injection; NoInt, no insulin injection.

Table 3: The impact of four dimensions on health literacy level.

Health knowledge Health skills Health awareness Health behavior

MDI 124.43905 105.48082 51.83094 44.86886
PCA 0.79163 0.77622 0.65468 0.5239
Abbreviations: MDI, mean decrease in impurity; PCA, principal component analysis.

multiple-choice questions that assess knowledge or skills, with 707 valid questionnaires remained for analysis. The basic
scores assigned based on the number of correct answers, up to information of the survey subjects is presented in Table 2.
a maximum of 5 points; and (2) Likert 5-point scale questions, Based on the HL scores, the study subjects were divided
with scores ranging from 1 to 5 based on the selected response. into two groups: the HL-deficient group, consisting of 320
The survey questionnaire demonstrated strong internal cases (45.3%) with scores below 130 points, and the HL-
consistency, with an overall Cronbach’s α coefficient of adequate group, consisting of 387 cases. Univariate analysis
0.904 and coefficients ranging from 0.848 to 0.875 across revealed significant differences in HL scores among diabetic
the four dimensions. The authority coefficient of the patients by sex, age, duration of disease, education level,
DHLEIS expert consultation results was 0.89, indicating a average monthly income, exercise, and the number of
high level of expert agreement. The concordance coeffi- cohabitants (p < 0 05).
cients from the two rounds of expert consultations were
0.362 and 0.358, respectively, suggesting substantial expert 3.3. The Impact of Basic Information-Related Factors on
approval of the content of the evaluation indicators. HL Level
Therefore, the survey questionnaire is considered to meet
validity requirements. 3.3.1. Analysis of the Importance of Basic Information on HL
Level. Using the %IncMSE and mean decrease in impurity
(MDI) metrics from the RF analysis, the importance of basic
3.2. Basic Information of the Survey Subjects. A total of 820 information related to HL was ranked (Figure 1). The results
questionnaires were distributed, and 800 were returned. indicate that nine factors—age, sex, body type, income, exer-
After excluding those with a large number of missing values, cise, education level, DM duration, whether insulin is
 1485, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/jdr/5110867, Wiley Online Library on [30/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Journal of Diabetes Research 7

Age
Body shape
Complication
Dietary control
DM duration
DM type
Education level
Features

Exercise
Family history
Income
Injection
Marital status
No intervention

No. of cohabitant
OHA
Sex

0 2 4 6 0 5 10 15 20 25 30 35 0 5 10 15 20 25 30 0 13 26 39
Health awareness Health knowledge Health behavior Health skills
Mean decrease in impurity

Figure 3: The impact of different influencing factors on the four dimensions of health literacy (health skills, health behavior, health
knowledge, and health awareness). The further to the right a point is, the greater the impact of that factor on the respective health
dimension. DM, diabetes mellitus; OHA, oral hypoglycemia agent.

injected, and the number of cohabitants—are important in tributes to the overall model, serving as a comparative refer-
both metrics. Notably, age and education level had the most ence. The results indicate that the contributions identified by
significant impact across both analyses. both methods are generally consistent, with health knowledge
and health skills contributing more significantly to HL levels,
3.3.2. Density Analysis of HL Levels Across Different while the impact of health awareness and health behavior is
Demographic Characteristics (User Profiling). Density plots comparatively lower.
of HL levels across key influencing factors were used to
depict user profiles for different HL levels (Figure 2). The 3.4.2. Analysis of the Importance of Basic Information Factors
analysis shows significant differences in the density distribu- on the Four Dimensions of HL. To better understand the
tion of HL levels in relation to body type, marital status, impact of basic information factors on the four dimen-
income, and education level. The age density plot reveals sions of HL, MDI analysis was employed to evaluate the
that older populations tend to have a higher proportion of importance of various factors across these dimensions
lower HL. In the distribution plot for education level, indi- (Figure 3). The results indicate that age, DM duration,
viduals with higher education levels generally exhibit higher education level, and the number of cohabitants signifi-
HL. User profiling based on HL levels can provide theoreti- cantly influence all four dimensions of HL. However, the
cal support for the development of personalized health inter- effect of individual factors varies across the dimensions.
vention measures. For instance, health awareness shows little variation
between sexes, but notable differences exist in health skills,
3.4. The Impact of Basic Information Factors on the Four behaviors, and knowledge (p < 0 05). Particularly in health
Dimensions of HL skills and knowledge, males exhibit a significant advantage,
whereas females demonstrate higher implementation
3.4.1. Analysis of the Contribution of the Four Dimensions of (health behavior).
HL to the Overall HL Level. The impact and contribution of
the four dimensions of HL—health awareness, health knowl- 3.4.3. Correlation Analysis Between Basic Information
edge, health behavior, and health skills—on the overall HL Factors and Four Dimensions of HL. The correlation matrix
level were assessed using RF and PCA (Table 3). The total between different factors of diabetic patients’ HL (Figure 4)
HL score served as the outcome variable, while the scores from reveals a strong positive correlation between health knowl-
each dimension were used as input variables for constructing edge and health skills (0.583), indicating that greater health
the RF model. The MDI metric reflects each variable’s contri- knowledge can significantly enhance health skills. The corre-
bution to the model’s classification performance, with the lations between education level and both health knowledge
higher values indicating greater importance. PCA was used and health skills are also relatively strong (0.319 and 0.474,
to understand the proportion of variance each dimension con- respectively), suggesting that higher education levels are
 1485, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/jdr/5110867, Wiley Online Library on [30/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
8 Journal of Diabetes Research

1.00
Health.score
Health.Skills
0.85
Health.Behavior
Health.Knowledge
0.70
Health.Awareness
Injection
OHA 0.55

Exercise
Dietary control 0.40

No intervention
Complication 0.25
No. of cohabitant
Income 0.10
Marital status
Education level –0.05
Body shape
Family history
–0.20
DM duration
DM type
–0.35
Age
Sex
–0.50
Marital status

Health.awareness

Health.skills
Age
DM type
DM duration

Body shape

Income

Complication
No intervention

Exercise

Injection

Health.knowledge

Health.score
OHA
Education level

Dietary control

Health.behavior
No. of cohabitant
Sex

Family history

Figure 4: Correlation analysis of basic information factors on the four dimensions of health literacy. Changes in color and numerical values
represent different levels of correlation, ranging from strong negative correlation (dark red, close to −1.0) to strong positive correlation (dark
green, close to 1.0). DM, diabetes mellitus; OHA, oral hypoglycemia agent.

associated with better health knowledge and skills. Con- improving health), Q18 (corresponding to B11: understand
versely, the type of DM shows a negative correlation with the side effects of diabetes-related drugs), Q25 (correspond-
both health awareness (−0.02) and health knowledge ing to C5: annual regular physical examination), and Q36
(−0.04). These findings provide insights for researchers and (corresponding to D7: can use traditional media such as
healthcare professionals into the factors influencing the paper literature and bulletin boards to obtain health educa-
health behavior and management of diabetic patients, aiding tion information) are identified as having relatively high
in the design of more effective interventions. importance for health awareness, knowledge, behavior, and
skills, respectively.
3.5. Layered Precision Analysis Based on the DHLEIS. This
section conducts a layered precision analysis of the key sec- 4. Discussion
ondary indicators and direct factors affecting the HL levels
of diabetic patients based on the DHLEIS system. Through In the context of precision medicine and personalized
the RF model, core secondary indicator factors influencing healthcare, the level of HL among diabetic patients plays a sig-
the HL of diabetic patients were identified (Figure 5(a)). nificant and positive role in their self-health management [25,
The results indicate that Q30 (corresponding to D1: can read 26]. This study developed the DHLEIS, a HL evaluation index
written information such as medical orders and drug system specifically for diabetic patients, and designed a corre-
instructions) has a significant impact on overall HL. The sponding HL questionnaire. A survey was conducted among
heat map of the importance of key questions for each dimen- diabetic patients across five hospitals, utilizing RF and other
sion (primary indicators) in Figure 5(b) highlights that Q2 analytical methods to thoroughly examine the impact of vari-
(corresponding to A2: willing to spend time and money ous influencing factors on overall HL and its four dimensions.
 1485, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/jdr/5110867, Wiley Online Library on [30/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Journal of Diabetes Research 9

Rank all questions in order of importance

40

35

Mean decrease in impurity

30

25

20

15

10

0
Q30 Q36 Q19 Q18 Q32 Q37 Q20 Q33 Q8 Q10
Questions
(a)

60
Q2 Q5 Q4 Q1 Q6 Q3
Awareness 14.61 13.97 13.16 12.86 8.50 8.30

50
Four dimensions

Mean decrease Gini

Q18 Q17 Q8 Q20 Q19 Q10 Q11 Q13 Q7 Q14 Q9 Q16 Q15 Q12
Knowledge 49.83 48.73 42.74 39.73 28.33 24.15 17.73 12.42 11.92 10.89 10.86 8.21 7.74 7.26 40

Q25 Q21 Q22 Q24 Q23 Q26 Q27 Q29 Q28 30

Behavior 55.79 49.45 40.59 30.25 29.73 29.38 28.33 18.00 13.67

20
Q36 Q35 Q34 Q30 Q33 Q37 Q39 Q38 Q32 Q31
Skill 64.34 62.17 46.52 37.69 31.71 29.17 26.49 19.50 13.34 8.94
10

Questions
(b)

Figure 5: Impact of secondary indicator system factors on overall and dimensional health literacy. (a) Screening of core secondary indicator
factors for health literacy in diabetic patients. (b) Importance ranking of secondary indicator factors for each health dimension (the darker
the color, the higher the importance).

Additionally, the core influencing factors were identified, and lack of continuous support from health resources due to geo-
their contributions were analyzed to support precise interven- graphical factors [33], all of which can result in a decline in HL
tions and personalized management of HL in diabetic patients. as the duration of DM increases.
From an overall and multidimensional perspective of There is a significant relationship between education
HL, nine factors—age, sex, body type, income, exercise, edu- level and both health knowledge and skills (positive correla-
cation level, DM duration, insulin injection, and number of tion coefficients: 0.41 and 0.63, respectively), consistent with
cohabitants—significantly impact HL level. Among these, the findings of İlhan et al. and Finbråten et al. [34, 35].
age, DM duration, education level, and number of cohabi- Therefore, as illustrated in the characteristic portrait of the
tants show greater importance across the four dimensions of diabetic population (Figure 2), it is essential to design and
health knowledge, awareness, behavior, and skills. Several implement targeted health promotion plans for populations
studies indicate that as the duration of the DM increases, HL with lower educational levels and older age. Studies from mul-
and disease management experience tend to improve [2, 27]. tiple regions indicate that interventions such as demonstration
However, the findings of this study are the opposite, indicating feedback [36], short message delivery interventions [37], and
that HL levels decrease with the increased duration of the dis- customized education supported by the physical environment
ease, aligning with the conclusions of Jafari et al. [9] and [2] are more effective in improving HL for these groups, par-
Mogessie et al. [28]. The reason for this outcome may include ticularly in terms of user experience and feasibility.
a lack of awareness regarding the long-term complications of The significance of secondary indicator factor Q30 (D1:
DM [29], reduced sensitivity to the disease, or cognitive understanding written medical orders and medication
decline [30]. Other contributing factors may include low instructions) is remarkably substantial, reinforcing the asser-
self-efficacy due to persistent lifestyle habits [31] (such as poor tion by Rafferty et al. that difficulties in understanding oral
dietary management [32]) that are difficult to change or the and written health information impede patients’ active
 1485, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/jdr/5110867, Wiley Online Library on [30/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
10 Journal of Diabetes Research

engagement in health management [38]. Currently, the the representativeness and generalization capability of the
correlation between cohabitation and HL remains incon- data in subsequent studies to enable wider applications in
sistent [39], with limited studies exploring the relationship smart health management for DM.
between the number of cohabitants or family members
and HL [40]. However, this study identifies a positive cor- 5. Summary and Prospects
relation between the number of cohabitants (family mem-
ber count) and DM health skills, potentially attributable to Based on the HL assessment standard system, analyzing the
support and assistance from family members, including multidimensional factors influencing HL can help character-
younger children. ize the features of populations with varying levels of HL,
Both RF and PCA reveal that health knowledge and enabling targeted cognitive improvements and effective
skills are crucial in influencing the level of HL, while the enhancement of health skills. This provides a framework
impact of health awareness and behavior is relatively for subsequent studies on group differences and personaliza-
minor. Unexpectedly, the significance of the other dimen- tion of HL, offering clear direction for further adjustments to
sions does not align consistently with the DHLEIS system the general applicability of this study.
based on expert opinions, except for health skills [41]. The With continuous advancements and empowerment from
hierarchy of importance presented in Table 2 corresponds technology, the evaluation and intervention of factors
with the theoretical comprehensive concept model of DHL influencing diabetes HL will become increasingly straight-
proposed by Sørensen et al. [42] and van der Vaart and forward and efficient. Additionally, considering regional
Drossaert [43]. This model posits that proficient health and individual differences allows patients to achieve a higher
skills foster healthier behaviors and improved health out- level of health empowerment, enabling data-driven precise
comes. The disparities also indicate that in the relational assessments, targeted improvements of HL levels, and metic-
concept of HL, individual-level factors and system ulous self-health management.
demands interact and determine HL [44]. Furthermore,
there is a specific sequence in this relational framework Data Availability Statement
such as the level of HL influencing the degree to which
health behaviors are implemented [45] rather than health The data that support the findings of this study are available
behaviors dictating the level of HL (i.e., the relationship on request from the corresponding author. The data are not
between HL and health efficacy [46]). Adequate health publicly available due to privacy or ethical restrictions.
knowledge is recognized as an important factor influencing
the evolution of patients’ coping strategies, which suggests Ethics Statement
that the more patients understand their conditions, the
better they can manage their health [47], a finding corrob- This study, including the patient consent process, has been
orated in this study. These insights provide direction for approved by the Medical Ethics Committee at Nantong Uni-
further research design and reference for the forthcoming versity (Ethical Approval 2021-030) and conforms to the
theoretical update of DHLEIS. ethical guidelines of the Declaration of Helsinki. Informed
oral consent was obtained from all patients before their par-
4.1. Innovations and Limitations. The innovations of this ticipation in the study.
study are manifold. Firstly, the study leverages expert opinion
to construct a HL evaluation index system specifically for dia- Conflicts of Interest
betic patients, providing a standard for the multidimensional
comprehensive evaluation of HL. Secondly, it develops a stan- The authors declare no conflicts of interest.
dardized questionnaire based on this standard to comprehen-
sively assess the HL of diabetic patients. Last but not least, the Author Contributions
study utilizes ML and multidimensional deep analysis to
examine the impact of different levels of influencing factors Y.C., Z.W., and F.J. contributed equally to this work. Y.C.
on HL, identifying key factors and thereby developing a rapid and K.J. designed the study. Z.W., F.J., and J.S. participated
assessment tool for the HL of diabetic patients (patent pend- in the conception of the study. Z.W. and F.J. conducted
ing). The identification of key factors not only improves com- the machine learning and interpreted the data. J.S. managed
munication efficiency between healthcare providers and the statistical analyses and supporting information. Z.W.
patients and enhances patient compliance but also supports and F.J. prepared Figures 1, 2, 3, 4, and 5. Y.C. wrote the first
the formulation of clinical decision-making and optimizes draft, and K.J. revised it to make the final manuscript. All
the allocation of medical resources. authors have approved the final manuscript.
However, the representativeness and external validity of
the study may be limited by the use of convenience sampling Funding
and the exclusion of participants with cognitive disabilities.
Additionally, the limitations of the DHLEIS framework This research was supported by the National Natural Science
and the choice of ML methods may render the results some- Foundation of China (10.13039/501100001809) (82102186)
what deficient in contextual adaptation and generalization. and the Postgraduate Research & Practice Innovation Pro-
Therefore, it is essential to further enhance and optimize gram of Jiangsu Province (KYCX23_3414).
 1485, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/jdr/5110867, Wiley Online Library on [30/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Journal of Diabetes Research 11

Acknowledgments [11] L. K. E. Hæsum, S. L. Cichosz, and O. K. Hejlesen, “Using

machine learning to design a short test from a full-length test
The authors of the study express their sincere gratitude to all of functional health literacy in adults-the development of a
participants who assisted the authors in running this study. short form of the Danish TOFHLA,” PLoS One, vol. 18,
no. 7, article e0280613, 2023.
[12] T. L. Endocrinology, “Diabetes care and AI: a looming threat
Supporting Information or a necessary advancement?,” The Lancet Diabetes & Endocri-
nology, vol. 11, no. 7, p. 441, 2023.
Additional supporting information can be found online in the [13] A. Nomura, M. Noguchi, M. Kometani, K. Furukawa, and
Supporting Information section. (Supporting Information) T. Yoneda, “Artificial intelligence in current diabetes manage-
Supporting Information S1. Original questionnaire on health ment and prediction,” Current Diabetes Reports, vol. 21,
literacy of people with diabetes. no. 12, p. 61, 2021.
[14] B. Sheng, K. Pushpanathan, Z. Guan et al., “Artificial intelli-
References gence for diabetes care: current and future prospects,” The Lan-
cet Diabetes & Endocrinology, vol. 12, no. 8, pp. 569–595, 2024.
[1] A. Jafari, F. Naddafi, M. Gholian-Aval, and H. Tehrani, “Rela- [15] G. Fagherazzi and P. Ravaud, “Digital diabetes: perspectives
tionship between diabetes health literacy, distress, burnout, for diabetes prevention, management and research,” Diabetes
social support, complications, self-care behaviors, and quality & Metabolism, vol. 45, no. 4, pp. 322–329, 2019.
of life among patients with type 2 diabetes: a path analysis
[16] F. İnceoğlu, S. Deniz, and F. H. Yagin, “Prediction of effective
study,” Diabetology & Metabolic Syndrome, vol. 16, no. 1,
sociodemographic variables in modeling health literacy: a
p. 150, 2024.
machine learning approach,” International Journal of Medical
[2] J. Butayeva, Z. A. Ratan, S. Downie, and H. Hosseinzadeh, Informatics, vol. 178, article 105167, 2023.
“The impact of health literacy interventions on glycemic con-
trol and self-management outcomes among type 2 diabetes [17] Y. Wu, H. Min, M. Li et al., “Effect of artificial intelligence-based
mellitus: a systematic review,” Journal of Diabetes, vol. 15, health education accurately linking system (AI-HEALS) for type
no. 9, pp. 724–735, 2023. 2 diabetes self-management: protocol for a mixed-methods
study,” BMC Public Health, vol. 23, no. 1, p. 1325, 2023.
[3] S. K. Simonds, “Health education as social policy,” Health Edu-
cation Monographs, vol. 2, 1 Supplement, pp. 1–10, 1974. [18] Y. Chen, X. Ran, Y. Chen, and K. Jiang, “Effects of health liter-
acy intervention on health literacy level and glucolipid metab-
[4] P. Chen, M. Callisaya, K. Wills, T. Greenaway, and
olism of diabetic patients in mainland China: a systematic
T. Winzenberg, “Cognition, educational attainment and dia-
review and meta-analysis,” Journal of Diabetes Research,
betes distress predict poor health literacy in diabetes: a cross-
vol. 2021, no. 1, Article ID 1503446, 2021.
sectional analysis of the SHELLED study,” PLoS One, vol. 17,
no. 4, article e0267265, 2022. [19] X. Ran, Y. Chen, K. Jiang, and Y. Shi, “The effect of health lit-
eracy intervention on patients with diabetes: a systematic
[5] C. Li, X. Zhao, K. Miyong, J. Quan, C. Li, and C. Li, “Impact of
review and meta-analysis,” International Journal of Environ-
disease-related health literacy on the control of blood glucose
mental Research and Public Health, vol. 19, no. 20, article
in community patients with diabetes mellitus,” Chinese Jour-
13078, 2022.
nal of Nursing, vol. 47, pp. 69–71, 2012, https://www.cnki
.net/KCMS/detail/detail.aspx?dbcode=CJFD%26dbname= [20] The State Council Information Office of the People's Republic
CJFD2012%26filename=ZHHL201201031%26uniplatform= of China (SCIO), “The Ministry of Health's "First Survey on
OVERSEA%26v=NY2HNj1AnQFfaLn0Qtnx Health Literacy of Chinese Residents" Release Conference,”
Ixwao2fc3xsB0KUfMIbvaGZWNnJ7UJLoQBjE-D8SD1oT. 2009, http://www.nhc.gov.cn/wsb/pxwfb/200912/45121
[6] Y. Chen, C. Yu, X. Liu et al., “PCLiON: an ontology for data .shtml. Access Date: July 10, 2024.
standardization and sharing of prostate cancer associated life- [21] R. F. DeVellis and C. T. Thorpe, Scale development: Theory and
styles,” International Journal of Medical Informatics, vol. 145, applications, Sage publications, 2021.
article 104332, 2021. [22] E. G. Özgür, A. Ulgen, S. Uzun, and G. N. Bekiroğlu, “Evalua-
[7] D. Goldberg, “Care of diabetes and the sacrifice of evidence- tion of risk factors and survival rates of patients with early-
based medicine and health equity,” Journal of General Internal stage breast cancer with machine learning and traditional
Medicine, vol. 39, no. 12, pp. 2333–2337, 2024. methods,” International Journal of Medical Informatics,
[8] A. Abdullah, S. M. Liew, H. Salim, C. J. Ng, and K. Chinna, vol. 190, article 105548, 2024.
“Prevalence of limited health literacy among patients with type [23] R. Nogueira, M. L. Cabo, L. García-Sanmartín, L. Sánchez-Rui-
2 diabetes mellitus: a systematic review,” PLoS One, vol. 14, loba, and J. J. Rodríguez-Herrera, “Risk factor-based clustering
no. 5, article e0216402, 2019. of listeria monocytogenes in food processing environments
[9] A. Jafari, M. Moshki, M. Ghelichi-Ghojogh, and M. Nejatian, using principal component analysis,” Food Research Interna-
“Role of diabetes health literacy, psychological status, self- tional, vol. 170, article 112989, 2023.
care behaviors, and life satisfaction in predicting quality of life [24] S. K. Gilhooley, W. A. Bauman, M. F. La Fountaine et al., “Car-
in type 2 diabetes,” Scientific Reports, vol. 14, no. 1, p. 1635, diometabolic risk factor clustering in persons with spinal cord
2024. injury: a principal component analysis approach,” The Journal
[10] W. Brown 3rd, R. Balyan, A. J. Karter et al., “Challenges and of Spinal Cord Medicine, vol. 47, no. 5, pp. 627–639, 2024.
solutions to employing natural language processing and [25] J. Zaletel and J. Farkaš Lainščak, “Creation of a different land-
machine learning to measure patients' health literacy and phy- scape for cardiovascular diseases and diabetes in Europe
sician writing complexity: the ECLIPPSE study,” Journal of through JACARDI joint action,” Slovenian Journal of Public
Biomedical Informatics, vol. 113, article 103658, 2021. Health, vol. 63, no. 3, pp. 109–112, 2024.
 1485, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/jdr/5110867, Wiley Online Library on [30/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
12 Journal of Diabetes Research

[26] D. RobatSarpooshi, M. Mahdizadeh, H. Alizadeh Siuki, [39] R. Langballe, M. C. Nilbert, J. Christensen, A. J. Tybjerg, and
M. Haddadi, H. Robatsarpooshi, and N. Peyman, “The rela- P. E. Bidstrup, “Understanding quality data correctly: a ran-
tionship between health literacy level and self-care behaviors domized comparison of presentation formats among cancer
in patients with diabetes,” Patient Related Outcome Measures, patients and relatives,” Acta Oncologica, vol. 61, no. 12,
vol. 11, pp. 129–135, 2020. pp. 1454–1462, 2022.
[27] S. Maleki, F. Rakhshani, G. Masoudi, and A. Ansari-Moghad- [40] R. Sapbamrer, N. Sittitoon, S. Thongtip et al., “Socio-demo-
dam, “Health literacy, knowledge and relevant factors in graphic, agricultural, and personal protective factors in rela-
patients with type 2 diabetes presenting to a diabetes clinic in tion to health literacy among farmers from all regions of
Zahedan in 2014,” Caspian Journal of Health Research, vol. 2, Thailand,” Frontiers in Public Health, vol. 12, article
no. 2, pp. 9–17, 2016. 1364296, 2024.
[28] H. M. Mogessie, M. A. Gebeyehu, M. G. Kenbaw, and T. A. [41] Y. Zhang, J. Li, Y. Hu et al., “Proactive health behavior in
Tadesse, “Diabetic health literacy and associated factors middle-aged and older adult females with urinary inconti-
among diabetes mellitus patients on follow up at public hospi- nence: a grounded theory study,” Neurourology and Urody-
tals, Bale Zone, South East Ethiopia, 2021,” PLoS One, vol. 17, namics, vol. 43, no. 8, pp. 2005–2016, 2024.
no. 7, article e0270161, 2022. [42] K. Sørensen, S. Van den Broucke, J. Fullam et al., “Health liter-
[29] P. Debnath, K. Natasha, L. Ali et al., “Ayurpharmacoepide- acy and public health: a systematic review and integration of
miology perspective: health literacy (knowledge and practice) definitions and models,” BMC Public Health, vol. 12, no. 1,
among older diabetes patients visiting Ayurveda teaching hos- p. 80, 2012.
pitals in India,” Journal of Evidence-Based Complementary & [43] R. van der Vaart and C. Drossaert, “Development of the digital
Alternative Medicine, vol. 22, no. 2, pp. 242–250, 2017. health literacy instrument: measuring a broad spectrum of
[30] M. B. Simonsen, S. L. Christiansen, M. K. Pedersen et al., health 1.0 and health 2.0 skills,” Journal of Medical Internet
“Health literacy and cognitive function in people with diabetic Research, vol. 19, no. 1, article e27, 2017.
foot ulcer with focus on knowledge, attitude, and practice in [44] R. Parker and S. C. Ratzan, “Health literacy: a second decade of
relation to foot self-care,” SAGE Open Medicine, vol. 12, article distinction for Americans,” Journal of Health Communication,
20503121241258841, 2024. vol. 15, Supplement 2, pp. 20–33, 2010.
[31] Y. Shao, H. Hu, Y. Liang et al., “Health literacy interventions [45] A. Jafari, Z. Zadehahmad, V. Armanmehr, M. Talebi, and
among patients with chronic diseases: a meta-analysis of ran- H. Tehrani, “The evaluation of the role of diabetes health liter-
domized controlled trials,” Patient Education and Counseling, acy and health locus of control on quality of life among type 2
vol. 114, article 107829, 2023. diabetes using the path analysis,” Scientific Reports, vol. 13,
[32] C. Campanino, A. Falone, E. Rossi et al., “Health literacy in no. 1, p. 5447, 2023.
female patients affected by anorexia nervosa and bulimia ner- [46] B. Kaplan, H. S. Koçak, and E. Kaplan Serin, “The relationship
vosa: a cross-sectional study with pair-matched controls,” Eat- between health literacy and diabetes self-efficacy and foot self-
ing and Weight Disorders-Studies on Anorexia, Bulimia and care in type II diabetics,” The International Journal of Lower
Obesity, vol. 28, no. 1, p. 59, 2023. Extremity Wounds, no. article 15347346241233366, 2024.
[33] F. B. Hailu, P. Hjortdahl, and A. Moen, “Nurse-led diabetes [47] Z. Yiran, Z. Yan, X. Lijun, L. Xizheng, Z. Xinjie, and T. Yutong,
self-management education improves clinical parameters in “Current status and influencing factors of activation of older
Ethiopia,” Frontiers in Public Health, vol. 6, p. 302, 2018. patients with chronic disease,” Frontiers in Public Health,
[34] N. İlhan, S. Telli, B. Temel, and T. Aştı, “Health literacy and vol. 11, article 1308196, 2023.
diabetes self-care in individuals with type 2 diabetes in Tur-
key,” Primary Care Diabetes, vol. 15, no. 1, pp. 74–79, 2021.
[35] H. S. Finbråten, Ø. Guttersrud, G. Nordström, K. S. Pettersen,
A. Trollvik, and B. Wilde-Larsson, “Explaining variance in
health literacy among people with type 2 diabetes: the associa-
tion between health literacy and health behaviour and empow-
erment,” BMC Public Health, vol. 20, no. 1, p. 161, 2020.
[36] C. Y. Lin, M. K. T. Cheung, A. T. F. Hung, P. K. K. Poon, S. C.
C. Chan, and C. C. H. Chan, “Can a modified theory of
planned behavior explain the effects of empowerment educa-
tion for people with type 2 diabetes?,” Therapeutic Advances
in Endocrinology and Metabolism, vol. 11, article
2042018819897522, 2020.
[37] L. A. Nelson, A. Spieker, R. Greevy, L. M. LeStourgeon, K. A.
Wallston, and L. S. Mayberry, “User engagement among
diverse adults in a 12-month text message-delivered diabetes
support intervention: results from a randomized controlled
trial,” JMIR mHealth and uHealth, vol. 8, no. 7, article
e17534, 2020.
[38] A. P. Rafferty, N. L. Winterbauer, H. Luo, R. A. Bell, and N. R.
G. Little, “Diabetes self-care and clinical care among adults
with low health literacy,” Journal of Public Health Manage-
ment and Practice, vol. 27, no. 2, pp. 144–153, 2021.